| Course | NU 636 Advanced Pharmacology |
|---|---|
| Unit | Unit 8 |
| Paper type | Comprehensive medication review |
| Length | About 1,020 words, 6 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN Family Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NU 636 Unit 8
Subtraction Before Selection: A Comprehensive Medication Review for an 82-Year-Old Woman With Falls and Low Blood Sugars
Student Name
Department of Nursing, Herzing University
NU 636: Advanced Pharmacology
Instructor Name
April 8, 2026
Subtraction Before Selection: A Comprehensive Medication Review for an 82-Year-Old Woman With Falls and Low Blood Sugars
The Patient, the Population Factor, and the Regimen
Mrs. R., a composite 82-year-old widow who lives alone with daily help from her son, is seen after two falls in six weeks and three episodes of shakiness and sweating before lunch, one with a fingerstick glucose of 58 mg/dL. She has type 2 diabetes, hypertension, mild Alzheimer disease, urinary urgency, chronic knee osteoarthritis, and chronic kidney disease, most recently measured at an eGFR of 32. Her A1C is 6.3%. Her weight is 121 pounds, and she is judged frail: slow gait, weak grip, and unintentional weight loss over the past year. Frailty, falls, and hypoglycemia are the population factors that will shape every decision below.
Her current medications are metformin 1,000 mg twice daily; glyburide 5 mg every morning; amlodipine 10 mg daily; lisinopril 20 mg daily; furosemide 20 mg daily; donepezil 10 mg at bedtime; oxybutynin 5 mg twice daily; amitriptyline 25 mg at bedtime, started years ago for sleep; omeprazole 20 mg daily for more than five years; atorvastatin 20 mg daily; and naproxen 220 mg one or two tablets most days, bought over the counter.
First Pass: Indication and Verdict for Every Agent
Metformin: indication diabetes, still valid, but the dose is too high for her kidney function. Glyburide: indication diabetes, but with an A1C of 6.3% in a frail older adult, the indication for intensive glucose lowering no longer holds; a target below 8.0% is appropriate for older adults with complex health status (American Diabetes Association Professional Practice Committee, 2024). Lisinopril: hypertension and kidney protection, valid. Amlodipine: hypertension, valid, but her ankle swelling began after the dose was raised to 10 mg. Furosemide: started for that ankle swelling; the indication is the side effect of another drug. Donepezil: Alzheimer disease, valid. Oxybutynin: urinary urgency, which began after donepezil was started. Amitriptyline: sleep, an indication with safer options, and the drug is strongly anticholinergic. Omeprazole: no current indication documented; started during a hospital stay for a prescription she no longer takes. Atorvastatin: cardiovascular prevention, reasonable to continue at her age if she values it. Naproxen: knee pain, with safer alternatives available.
The first pass surfaces two prescribing cascades, in which a drug is prescribed to treat the adverse effect of another. Furosemide was added for amlodipine-induced edema, which is caused by arteriolar dilation and does not respond well to diuretics. Oxybutynin was added for urinary urgency that followed donepezil, and the combination sets a cholinesterase inhibitor against an anticholinergic. Gill et al. (2005) documented exactly this cascade in older adults with dementia.
Second Pass: Interactions by Pathway and Consequence
Naproxen with lisinopril and furosemide: naproxen blocks renal prostaglandins that maintain afferent arteriolar flow, lisinopril relaxes the efferent arteriole, and furosemide reduces volume. Together they remove the kidney's ability to maintain filtration pressure, a recognized pathway to acute kidney injury in someone whose eGFR is already 32.
Donepezil with oxybutynin: the two drugs act in opposite directions on muscarinic receptors. Oxybutynin crosses the blood-brain barrier and can worsen cognition, directly opposing the reason donepezil was prescribed.
Amitriptyline with oxybutynin: additive anticholinergic burden, producing confusion, constipation, urinary retention, and dry mouth, and raising fall risk through sedation and orthostatic hypotension. The Beers Criteria advise avoiding strongly anticholinergic drugs in older adults and specifically in dementia (2023 American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
Glyburide with reduced kidney function: glyburide and its active metabolites are cleared partly by the kidney, and accumulation prolongs hypoglycemia, which is why the Beers Criteria list it among drugs to avoid in older adults. Her pre-lunch lows fit this mechanism.
Third Pass: Organ Function and Dose Arithmetic
Her eGFR of 32 falls in the range where metformin should not be started and, if continued, should be reduced; a maximum of 1,000 mg daily is commonly used at an eGFR between 30 and 45. Her current 2,000 mg daily is therefore halved to 500 mg twice daily. Using Cockcroft-Gault with her age, weight of 55 kg, and serum creatinine of 1.4 mg/dL, her creatinine clearance is about (140 minus 82) times 55, divided by (72 times 1.4), then multiplied by 0.85 for female sex, which gives roughly 27 mL/min. That lower estimate reinforces the metformin reduction and means her kidney function must be rechecked before any further change. Atorvastatin requires no adjustment.
Deprescribing
Removed now: glyburide, stopped today without a taper, because it provides no benefit at her A1C and is the probable cause of her hypoglycemia. Naproxen, stopped today, and for her knees she is offered topical diclofenac gel plus acetaminophen, 650 mg taken as often as three times a day.
Tapered: amitriptyline, reduced to 10 mg at bedtime for two weeks, then stopped, because abrupt withdrawal can cause cholinergic rebound with nausea, malaise, and poor sleep. Sleep hygiene is reviewed with her son. Omeprazole, reduced to 20 mg every other day for four weeks and then stopped, with on-demand use allowed if heartburn returns.
Planned for the next visit, one change at a time: reduce amlodipine to 5 mg and, if the edema resolves, stop furosemide; then stop oxybutynin and reassess her urinary symptoms, using timed voiding first. Sequencing matters, because changing several agents at once in a frail patient makes it impossible to tell which change caused a new problem (Scott et al., 2015).
Rebuilt Monitoring
Fingerstick glucose before breakfast and before lunch daily for two weeks, then three times weekly, with a call if any value is below 80 or above 300 mg/dL. Basic metabolic panel in one week, after stopping naproxen and reducing metformin, to confirm stable kidney function and potassium. A1C in three months, aiming below 8.0%. Home blood pressure, seated and standing, three times weekly, because the changes to amlodipine and furosemide will affect it. A fall diary kept by her son. Cognitive check at the next visit, since removing two anticholinergic drugs may improve it. A removed medication returns only for a documented reason: glyburide would not return; a low-dose antihypertensive would be added back if home blood pressure stayed above 150/90.
References
American Diabetes Association Professional Practice Committee. (2024). 13. Older adults: Standards of care in diabetes-2024. Diabetes Care, 47(Suppl. 1), S244-S257. https://doi.org/10.2337/dc24-S013
2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Gill, S. S., Mamdani, M., Naglie, G., Streiner, D. L., Bronskill, S. E., Kopp, A., Shulman, K. I., Lee, P. E., & Rochon, P. A. (2005). A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Archives of Internal Medicine, 165(7), 808-813. https://doi.org/10.1001/archinte.165.7.808
Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D., Gnjidic, D., Del Mar, C. B., Roughead, E. E., Page, A., Jansen, J., & Martin, J. H. (2015). Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Internal Medicine, 175(5), 827-834. https://doi.org/10.1001/jamainternmed.2015.0324
Reading the NU 636 Unit 8 instructions
The final NU 636 assignment asks for a comprehensive pharmacological review of a complex patient, usually an older adult or someone with multiple conditions and medications. Expect to evaluate every drug for indication, effectiveness, safety and dose, then identify interactions and the effect of organ function and age on each choice. Deprescribing is often a central requirement, with a plan for what to stop, reduce or taper and in what order. Monitoring after the changes should be specific, with tests and timing. Tools such as the Beers criteria are commonly expected for older adults. Cite current guidelines and evidence in APA 7. Expect this to be the longest paper of the term; the classroom gives the page range. Use a composite case and make sure each recommendation is tied to a finding about the patient.
Inside the NU 636 Unit 8 example
The review opens with the patient, her living situation and the population factor that shapes every decision: advanced age with reduced kidney function. The first pass takes each medication in turn and gives an indication and a verdict, such as continue, reduce or stop. Glyburide is flagged because a tight A1C in a frail older adult adds hypoglycemia risk without benefit. The second pass groups interactions by mechanism, explaining how naproxen, lisinopril and furosemide together threaten kidney function. The third pass applies her filtration rate to metformin dosing. The deprescribing section states what is stopped today, what is reduced and what alternative is offered, such as topical treatment for her knee pain. Monitoring is rebuilt with glucose checks, a metabolic panel after the changes and a follow-up visit.
NU 636 Unit 8 rubric: what full points look like
Herzing rubrics for the final case study usually allocate points to medication assessment, interaction analysis, consideration of organ function and population factors, the revised regimen, monitoring and evidence. Medication assessment is credited when every agent receives an indication and a reasoned verdict. Interaction points require mechanisms, not only drug pairs. Organ function and age points depend on accurate dose adjustments with the numbers shown. The revised regimen and deprescribing plan often carry the most weight, and markers look for clear actions with reasons and safe sequencing. Monitoring points go to specific follow-up linked to the changes made. Evidence is scored on current guidelines, including the Beers criteria where relevant, cited in APA format. Writing points reward an organized structure that another prescriber could follow.
NU 636 Unit 8 help: mistakes that cost points
Comprehensive reviews often lose points by commenting on the obvious problem drug and leaving the rest of the list unexamined. Students also add new medications to treat side effects instead of removing the cause. Kidney function is frequently cited without being applied to doses. Interactions are listed by name with no mechanism or consequence. Another common gap is stopping several drugs at once without considering which need a taper. Monitoring after changes is often missing or vague. Citing the Beers criteria without saying which recommendation applies earns little. Finally, keep the patient's goals and situation in view, such as living alone with help from family, because the safest regimen is one she can follow and that her helpers can check.
Get a NU 636 Unit 8 example written to your instructions
Send the Unit 8 instructions and the rubric from your NU 636 classroom, plus the case, the medication list and any population factor you were given. We write a custom example against those criteria, with interactions traced, doses adjusted and a justified removal, and return it in 24 to 48 hours. The first custom sample is free.
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NU 636 Unit 8 questions, answered
What makes a case comprehensive rather than merely long?
Decisions per medication. A comprehensive review reaches a verdict on every agent in the regimen, adjusts what needs adjusting, removes what no longer earns its place and rebuilds monitoring around the result. Length that comes from describing each drug in detail, without deciding anything, produces a long document that a grader reads as thorough background and thin analysis.
How do I handle a population factor such as age or pregnancy?
Let it touch every decision rather than sit in its own paragraph. If the composite patient is older, it changes which agents are reasonable, what doses start low, which adverse effects matter more and how often monitoring happens. Cite guidance written for that population where it exists, and say plainly which of your choices would differ without that factor.
How is the final unit different from the earlier plan work?
Plan work builds forward from one condition and one chosen agent. This deliverable inherits a regimen someone else assembled and has to judge all of it at once, including interactions between decisions made at different times. The hardest part is subtraction, since removing a medication requires defending the removal rather than the addition, and that argument appears nowhere earlier in the course.
Where can I find a free NU 636 Unit 8 sample paper?
This page holds the complete NU 636 Unit 8 medication review free, with all three passes, the deprescribing decisions and the rebuilt monitoring. If your final case involves a different patient, send it with your rubric and a custom review is prepared free, normally within 48 hours.
How do I deprescribe for an older adult in a NU 636 case study?
Review each medication for a current indication and benefit, flag those listed in the Beers criteria or causing harm, and decide which to stop now, reduce or taper. Offer safer alternatives where needed, and set specific monitoring after each change.